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Unexpected medical events call for quick investigation

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Determining best practices for investigating medical errors can help health care organizations quickly figure out what went wrong and implement changes that can improve safety, according to executives from Bronson Healthcare Group in Kalamazoo, Michigan.

Christine Sangalli, vice president of risk and compliance at Bronson, spoke of the time a nurse from one of the group’s facilities gave an orthopedic patient an incorrect medication, which caused the patient to go into cardiac arrest. Bronson immediately mobilized its internal “clinical scene investigation” team to determine how the nurse gave the wrong medication.

“We knew right away the error that the nurse had made,” Ms. Sangalli said of the investigation team’s findings, speaking Tuesday during the American Society for Healthcare Risk Management’s annual conference in Indianapolis.

After determining that the mistake happened because certain prescription medications were organized in a potentially confusing way, Bronson changed how those medications were organized to prevent similar errors from occurring in the future, Ms. Sangalli said. The patient was moved to Bronson’s intensive care unit and was able to receive life-saving medical care, she added.

Joan Porcaro, director of system risk management and privacy officer at Bronson, said the health system has separate investigation and risk management teams. The specially trained investigation team is prepared to respond within one hour when a medical error occurs, similar to how certain medical teams are called to provide immediate medical care when a patient’s life is in danger. “That team is geared up for critical events,” Ms. Porcaro said.

In addition to finding how errors occur, Bronson’s investigation team also assists the system’s health care employees, such as by providing guidance on how employees should approach patients and families about errors, and helping to provide mental and emotional support for employees who’ve erred.

Ms. Sangalli said that Bronson includes details of the health care system’s investigation process on its intranet so employees can understand how the process works.